2013 AAHA/AAFP Fluid Therapy Guidelines For Dogs And
2013 AAHA/AAFP Fluid TherapyGuidelines for Dogs and CatsIMPLEMENTATIONTOOLKIT
Inside This ToolkitWhy Guidelines Matter.3Understand the Guidelines’ Key Points.42013 AAHA/AAFP Fluid Therapy Guidelines for Dogs and Cats.5Improve Your Practice with a Model Protocol.16Make Uniform Decisions with a Model Algorithm.17Clarify Staff Roles and Responsibilities.19Answer 5 Common Client Questions.20Educate Clients with a Simple Handout.21Verify Key Tasks as You Perform Them.22AAHA Standardsof AccreditationThe AAHA Standards include standardsthat address fluid therapy.For information on how accreditation can help yourpractice provide the best care possible to your patients,visit aahanet.org/accreditation or call 800-252-2242.Free web conference available now!Join Heidi Shafford, DVM, PhD, DACVAA, for anengaging discussion on best practices for veterinarystaff to implement the 2013 AAHA/AAFP Fluid TherapyGuidelines for Dogs and Cats. Earn 1 hour of CE credit.Go to aahanet.org/Education/webconferences.aspx 2013 AAHA, iStockphoto.com/Iain Sarjeant
Why Guidelines MatterVeterinary practice guidelines, such as the recently published 2013AAHA/AAFP Fluid Therapy Guidelines for Dogs and Cats, help toensure that pets get the best possible care. Guidelines keep yourhospital staff—from medical director to veterinary assistant—on thecutting edge of veterinary medicine.The 2013 AAHA/AAFP Fluid Therapy Guidelines for Dogs and Cats is themost complete and medically sound compilation of updates, insights,advice and recommendations ever developed for helping to ensure thatyour patients receive appropriate, individualized fluid therapy.AAHA guidelines review the latest information that helps the veterinary team address treatment challenges and perform essential tasks inorder to improve the health of the pet. In addition, guidelines definethe role of each staff member, so everyone on the health care team canwork together to offer the best-quality medical care.Guidelines are just that—a guide established by experts in aparticular area of veterinary medicine. Guidelines do not outweighthe veterinarian’s clinical judgment; instead, they help veterinariansdevelop and carry out treatment plans that meet each patient’s needsand circumstances.Aligning your practice’s protocols with guideline recommendations is akey step in ensuring that your practice continues to deliver the best care.To support your dedicated efforts, AAHA is pleased to offer thistoolkit. Here, you’ll find facts, figures, highlights, tips, clienthandouts and other tools you can use every day to implement therecommendations of the 2013 AAHA/AAFP Fluid Therapy Guidelinesfor Dogs and Cats.Thank you for helping to advance our shared mission to deliver the bestin companion animal medical care. Together, we can make a difference!Michael T. Cavanaugh, DVM, DABVPAAHA Chief Executive OfficerWhen selecting fluid therapy products, as well as other types of products, veterinarianshave a choice of products formulated for humans and those developed and approvedfor veterinary use. Manufacturers of veterinary-specific products spend resources tohave their products reviewed and approved by the U.S. Food and Drug Administrationfor canine and/or feline use. These products are specifically designed and formulatedfor dogs and cats and have benefits for their use; they are not human generic products.AAHA suggests that veterinary professionals make every effort to use veterinary FDAapproved products and base their inventory purchasing decisions on what product ismost beneficial to the patient.3
Summary of Key PointsIndividualized careyy Fluid therapy must be individualized and tailored to each patient.yy Therapy is constantly re-evaluated and reformulated according to changes in patient status.yy Fluid selection is dictated by the patient’s needs, including volume, rate and fluid composition required, andlocation the fluid is needed (interstitial versus intravascular).yy The appropriate route of fluid administration depends on the patient’s condition. Use oral fluids for patients with a functioning gastrointestinal system and no significant fluid imbalance. Use subcutaneous fluids to prevent losses. This route is not adequate for replacement therapy in anything otherthan very mild dehydration. Use intravenous or intra-osseous fluids for patients undergoing anesthesia; for hospitalized patients not eating ordrinking normally; and to treat dehydration, shock, hyperthermia or hypotension.Fluids during anesthesiayy The decision about whether to provide fluids during anesthesia, and the type and volume used, depends on thepatient’s signalment, physical condition, and the length and type of procedure.yy Current recommendations are for less than 10 mL/kg/hr to avoid adverse effects of hypervolemia. Consider startingthe anesthetic procedure at 3 mL/kg/hr in cats and 5 mL/kg/hr in dogs.Maintenance fluid ratesCat: Formula 80 body weight (kg)0.75 per 24 hr Rule of thumb 2–3 mL/kg/hrDog: Formula 132 body weight (kg)0.75 per 24 hr Rule of thumb 2–6 mL/kg/hrFluids for the sick patientAssess for three types of fluid disturbances.1. Changes in volume (e.g., dehydration, blood loss, heart disease)a. Fluid deficit calculation for dehydration: body weight (kg) x % dehydration volume in liters to correct.See section on dehydration for more details on determining timeframe for replacement of deficit.b. Treatment for hypervolemia includes correcting underlying disease (e.g., chronic renal disease, heart disease)decreasing or stopping fluid administration, and possibly use of diuretics.2. Changes in content (e.g., hyperkalemia, diabetes or renal disease)a. In general, the choice of fluid is less important than the fact that it is isotonic. Volume benefits the patient muchmore than exact fluid composition. Isotonic fluids will begin to bring the body’s fluid composition closer tonormal, pending laboratory results that will guide more specific fluid therapy.3. Changes in distribution (e.g., pleural effusion, edema)a. For pulmonary edema or pleural/abdominal effusions, stop fluid administration.Staffing and monitoringyy Provide staff training on assessment of patient fluid status, catheter placement and maintenance, use andmaintenance of equipment related to fluid administration, benefits and risks of fluid therapy, and drug/fluidincompatibility.4yy Use equipment and supplies that enhance patient safety, such as fluid pumps, small fluid bags, Luer-lockconnections and Elizabethan collars.
2013 AAHA/AAFP Fluid Therapy Guidelines for Dogs and Cats*Harold Davis, BA, RVT, VTS (ECC), Tracey Jensen, DVM, DABVP, Anthony Johnson, DVM, DACVECC, Pamela Knowles, CVT, VTS (ECC),Robert Meyer, DVM, DACVAA, Renee Rucinsky, DVM, DAVBP (Feline), Heidi Shafford, DVM, PhD, DACVAAAbstractFluid therapy is important for many medical conditions in veterinary patients. The assessment of patient history, chief complaint,physical exam findings, and indicated additional testing will determine the need for fluid therapy. Fluid selection is dictated by thepatient’s needs, including volume, rate, fluid composition required, and location the fluid is needed (e.g., interstitial versus intravascular).Therapy must be individualized, tailored to each patient, and constantly re-evaluated and reformulated according to changes in status.Needs may vary according to the existence of either acute or chronic conditions, patient pathology (e.g., acid-base, oncotic, electrolyteabnormalities), and comorbid conditions. All patients should be assessed for three types of fluid disturbances: changes in volume,changes in content, and/or changes in distribution. The goals of these guidelines are to assist the clinician in prioritizing goals, selectingappropriate fluids and rates of administration, and assessing patient response to therapy. These guidelines provide recommendationsfor fluid administration for anesthetized patients and patients with fluid disturbances.IntroductionThese guidelines will provide practical recommendations for fluidchoice, rate, and route of administration. They are organized bygeneral considerations, followed by specific guidelines for perianesthetic fluid therapy and for treatment of patients with alterationsin body fluid volume, changes in body fluid content, and abnormal distribution of fluid within the body. Please note that theseguidelines are neither standards of care nor American AnimalHospital Association (AAHA) accreditation standards and shouldnot be considered minimum guidelines. Instead these guidelinesare recommendations from an AAHA/American Association ofFeline Practitioners (AAFP) panel of experts.Therapy must be individualized and tailored to each patientand constantly re-evaluated and reformulated according tochanges in status. Fluid selection is dictated by the patient’s needs,including volume, rate, and fluid composition required, as wellas location the fluid is needed (interstitial versus intravascular).Factors to consider include the following:yy Acute versus chronic conditionsyy Patient pathology (e.g., acid-base balance, oncotic pressure,electrolyte abnormalities)yy Comorbid conditionsFrom the University of California Davis, Veterinary Medical Teaching Hospital, Davis, CA (H.D.);Wellington Veterinary Clinic, PC, Wellington, CO (T.J.); Department of Veterinary Clinical Sciences,College of Veterinary Medicine, Purdue University, West Lafayette, IN (A.J.); WestVet AnimalEmergency and Specialty Center, Garden City, ID (P.K.); Mississippi State University College ofVeterinary Medicine, Mississippi State, MS (R.M.); Mid Atlantic Cat Hospital, Cordova, MD (R.R.); andVeterinary Anesthesia Specialists, LLC, Milwaukie, OR (H.S.).Correspondence: shafford@vetanesthesiaspecialists.com (H.S.) and arpest7@hotmail.com (R.R)A variety of conditions can be effectively managed using threetypes of fluids: a balanced isotonic electrolyte (e.g., a crystalloidsuch as lactated Ringer’s solution [LRS]); a hypotonic solution (e.g.,a crystalloid such as 5% dextrose in water [D5W]); and a syntheticcolloid (e.g., a hydroxyethyl starch such as hetastarch or tetrastarch).General Principles and Patient AssessmentThe assessment of patient history, chief complaint, and physical exam findings will determine the need for additional testingand fluid therapy. Assess for the following three types of fluiddisturbances:1. Changes in volume (e.g., dehydration, blood loss)2. Changes in content (e.g., hyperkalemia)3. Changes in distribution (e.g., pleural effusion)The initial assessment includes evaluation of hydration, tissueperfusion, and fluid volume/loss. Items of particular importancein evaluating the need for fluids are described in Table 1. Next,develop a treatment plan by first determining the appropriateroute of fluid administration. Guidelines for route of administration are shown in Table 2.Consider the temperature of the fluids. Body temperature(warmed) fluids are useful for large volume resuscitation but*This document is intended as a guideline only. Evidence-based support for specific recommendationshas been cited whenever possible and appropriate. Other recommendations are based on practicalclinical experience and a consensus of expert opinion. Further research is needed to documentsome of these recommendations. Because each case is different, veterinarians must base theirdecisions and actions on the best available scientific evidence, in conjunction with their ownexpertise, knowledge, and experience. These guidelines are supported by a generous educationalgrant from Abbott Animal Health.AAFP, American Association of Feline Practitioners; AAHA, American Animal Hospital Association; BP, blood pressure; D5W, 5% dextrose in water; DKA, diabetic ketoacidosis; K, potassium; KCl, potassiumchloride; LRS, lactated Ringer’s solution5
2013 AAHA/AAFP Fluid Therapy Guidelines for Dogs and Catsprovide limited usefulness at low IV infusion rates. It is not possible to provide sufficient heat via IV fluids at limited infusionrates to either meet or exceed heat losses elsewhere.1Fluids for Maintenance and ReplacementWhether administered either during anesthesia or to a sick patient,fluid therapy often begins with the maintenance rate, which is theamount of fluid estimated to maintain normal patient fluid balance (Table 3). Urine production constitutes the majority of fluidloss in healthy patients.2,3 Maintenance fluid therapy is indicatedfor patients that are not eating or drinking, but do not have volume depletion, hypotension, or ongoing losses.Replacement fluids (e.g., LRS) are intended to replace lost bodyfluids and electrolytes. Isotonic polyionic replacement crystalloidssuch as LRS may be used as either replacement or as maintenancefluids. Using replacement solutions for short-term maintenancefluid therapy typically does not alter electrolyte balance; however,electrolyte imbalances can occur in patients with renal disease orin those receiving long-term administration of replacement solutions for maintenance.Administering replacement solutions such as LRS for maintenance predisposes the patient to hypernatremia and hypokalemiabecause these solutions contain more sodium (Na) and less potassium (K) than the patient normally loses.Well-hydrated patientswith normal renal function are typically able to excrete excessNa and thus do not develop hypernatremia. Hypokalemia maydevelop in patients that receive replacement solutions for maintenance fluid therapy if they are either anorexic or have vomiting ordiarrhea because the kidneys do not conserve K very well.4If using a replacement crystalloid solution for maintenancetherapy, monitor serum electrolytes periodically (e.g., q 24 hr).Maintenance crystalloid solutions are commercially available.TABLE 1Evaluation and Monitoring Parameters that MayBe Used for Patients Receiving Fluid Therapyyy Pulse rate and qualityyy Capillary refill timeyy Mucous membrane coloryy Respiratory rate and effortyy Lung soundsyy Skin turgoryy Body weightyy Urine outputyy Mental statusyy Extremity temperatureBP, blood pressure.6yy Packed cell volume/total solidsyy Total proteinyy Serum lactateyy Urine specific gravityyy Blood urea nitrogenyy Creatinineyy Electrolytesyy BPyy Venous or arterial blood gasesyy O2 saturationAlternatively, fluid made up of equal volumes of replacement solution and D5W supplemented with K (i.e., potassium chloride[KCl], 13–20 mmol/L, which is equivalent to 13–20 mEq/L)would be ideal for replacing normal ongoing losses because of thelower Na and higher K concentration. Another option for a maintenance fluid solution is to use 0.45% sodium chloride with 13–20mmol/L KCl added.5 Additional resources regarding fluid therapyand types of fluids are available on the AAHA and AAFP websites.Fluids and AnesthesiaOne of the most common uses of fluid therapy is for patientsupport during the perianesthetic period. Decisions regardingwhether to provide fluids during anesthesia and the type andvolume used depend on many factors, including the patient’ssignalment, physical condition, and the length and type of theprocedure. Advantages of providing perianesthetic fluid therapyfor healthy animals include the following:yy Correction of normal ongoing fluid losses, support ofcardiovascular function, and ability to maintain wholebody fluid volume during long anesthetic periodsyy Countering of potential negative physiologic effects associatedwith the anesthetic agents (e.g., hypotension, vasodilation)yy Continuous flow of fluids through an IV catheter preventsclot formation in the catheter and allows the veterinaryteam to quickly identify problems with the catheter priorto needing it in an emergencyWhen fluids are provided, continual monitoring of theassessment parameters is essential (Table 1). The primary risk ofproviding excessive IV fluids in healthy patients is the potential forvascular overload. Current recommendations are to deliver 10mL/kg/hr to avoid adverse effects associated with hypervolemia,particularly in cats (due to their smaller blood volume), and allpatients anticipated to be under general anesthesia for long periodsof time (Table 4).6–8 In the absence of evidence-based anesthesiafluid rates for animals, the authors suggest initially starting at 3mL/kg/hr in cats and 5 mL/kg/hr in dogs. Preoperative volumeloading of normovolemic patients is not recommended.The paradigm of “crystalloid fluids at 10 mL/kg/hr, withhigher volumes for anesthesia-induced hypotension” is not evidence-based and should be reassessed. Those high fluid rates mayactually lead to worsened outcomes, including increased bodyweight and lung water; decreased pulmonary function; coagulation deficits; reduced gut motility; reduced tissue oxygenation;increased infection rate; increased body weight; and positive fluidbalance, with decreases in packed cell volume, total protein concentration, and body temperature.9,10 Note that infusion of 10–30mL/kg/hr LRS to isoflurane-anesthetized dogs did not changeeither urine production or O2 delivery to tissues.11 A fluidconsuming “third space” has never been reliably shown, and, in humans,blood volume was unchanged after overnight fasting.12
2013 AAHA/AAFP Fluid Therapy Guidelines for Dogs and Cats 2013 AAHAPreanesthetic Fluids and Preparing the Sick PatientCorrect fluid and electrolyte abnormalities in the sick patient asmuch as possible before anesthesia by balancing the need for preanesthetic fluid correction with the condition requiring surgery.For example, patients with uremia benefit from preanestheticfluid administration.13 Further, develop a plan for how fluids willbe used in an anesthesia-related emergency based on individualcomoribund conditions, such as hypertrophic cardiomyopathyand oliguric/polyuric renal disease.Monitoring and Responding to Hypotension During AnesthesiaBlood pressure (BP) is the parameter often used to estimate tissue perfusion, although its accuracy as an indicator of blood flowis not certain.11,14,15 Hypotension under anesthesia is a frequentoccurrence, even in healthy anesthetized veterinary patients.Assess excessive anesthetic depth first because it is a commoncause of hypotension.7,16 Exercise caution when using fluid therapy as the sole method to correct anesthesia-related hypotensionas high rates of fluids can exacerbate complications rather thanprevent them.10,11If relative hypovolemia due to peripheral vasodilation is contributing to hypotension in the anesthetized patient, proceed asdescribed in the following list:yy Decrease anesthetic depth and/or inhalant concentration.yy Provide an IV bolus of an isotonic crystalloid such as LRS(3–10 mL/kg). Repeat once if needed.yy If response is inadequate, consider IV administration of acolloid such as hetastarch. Slowly administer 5–10 mL/kgfor dogs and 1–5 mL/kg for cats, titrating to effect tominimize the risk of vascular overload (measure BP every3–5 min).9 Colloids are more likely to increase BP thancrystalloids.15yy If response to crystalloid and/or colloid boluses isinadequate and patient is not hypovolemic, techniquesother than fluid therapy may be needed (e.g., vasopressorsor, balanced anesthetic techniques).9yy Caution: Do not use hypotonic solutions to correcthypovolemia or as a fluid bolus because this can lead tohyponatremia and water intoxication.Postanesthetic Fluid TherapyPostanesthetic fluid administration varies based on intra-anesthetic complications and comorbid conditions. Patients thatmay benefit from fluid
3 Why Guidelines Matter Veterinary practice guidelines, such as the recently published 2013 AAHA/AAFP Fluid
the 2020 AAHA/AAFP Feline Vaccination Guidelines and resources through an educational grant to AAHA. † A. E. S. Stone was chair of the 2020 AAHA/AAFP Feline Vaccination Guidelines Task Force. These guidelines were prepared by a Task Force of experts convened by the American Ani
Animal Hospital Association (AAHA) accreditation standards and should not be considered minimum guidelines. Instead these guidelines are recommendations from an AAHA/American Asso-ciation of Feline Practitioners (AAFP) panel of experts. Therapy must be individualized and tailored to each patient andconstantlyre .
The robust advances in pain management for companion animals underlie the decision of AAHA and AAFP to expand on the information provided in the 2007 AAHA/AAFP Pain Management Guidelines for Dogs and Cats. The 2015 guidelines summarize and offer a discriminating review of much of this new knowledge. Pain management is central to veterinary
AAHA Members 15,131 Veterinarians 15,787 Veterinary assistants and support staff 6,722 Veterinary technicians 3,946 Practice managers 2,589 Other 44,175 TOTAL MEMBERS *Financial and Productivity Pulsepoints, Tenth Edition, AAHA Press, 2019. **As of July 1, 2020 2 Billion purchasing power* 4,511 AAHA-accredited and preaccredited .
AAFP Scientific Assembly. 1991 Fall:15-16. Nussbaum MR. Report on the National Conference of Women, Minority, and New Physicians. 1992 Fall:5, 8. Fogarty JP. News from the AAFP Committees and Commissions. 1993 Summer:9, 18. Yowell C. 1994 AAFP Staff Fellowship Opportunities. 1993 Fall:8. Clark JB. Report from AAFP Leadership Conference. 1993 .
L M A B CVT Revision: December 2006 2007 Sentra CVT FLUID PFP:KLE50 Checking CVT Fluid UCS005XN FLUID LEVEL CHECK Fluid level should be checked with the fluid warmed up to 50 to 80 C (122 to 176 F). 1. Check for fluid leakage. 2. With the engine warmed up, drive the vehicle to warm up the CVT fluid. When ambient temperature is 20 C (68 F .
The AAHA Vaccine Guidelines Are Created These early recommendations prompted the American Animal Hospital Association (AAHA) to assemble a task force. In 2003, the AAHA Canine Vaccine Task Force evaluated the data from these challenges and serological studies and, while noting that the core vaccines had a min-
Astrology: The alignment of the planets and stars was very important, looking at when the patient was born and fell ill to decide what was wrong with them! This became more popular after the Black Death (1348) Astrology is a SUPERNATURAL explanation for disease. Apothecaries mixed ingredients to make ointments and medicines for the physicians. They learned from other apothecaries. They also .
